Non-Medication Treatments Evaluation of Patient Encounter
Order ID 53563633773 Type Essay Writer Level Masters Style APA Sources/References 4 Perfect Number of Pages to Order 5-10 Pages Description/Paper Instructions
Non-Medication Treatments Evaluation of Patient Encounter
SOAP NOTE
Name: Date: Time: Age: Sex: SUBJECTIVE CC:
Reason given by the patient for seeking medical care “in quotes”
HPI:
Describe the course of the patient’s illness, including when it began, character of symptoms, location
where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.
Medications: (list with reason for med)
PMH
Allergies:
Medication Intolerances:
Chronic Illnesses/Major traumas
Hospitalizations/Surgeries
“Have you ever been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart
disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.”
Family History
Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with:
lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.
Social History
Education level, occupational history, current living situation/partner/marital status, substance use/abuse,
ETOH, tobacco, marijuana. Safety status
ROS General
Weight change, fatigue, fever, chills, night sweats,
energy level
Cardiovascular
Chest pain, palpitations, PND, orthopnea, edema
Skin
Delayed healing, rashes, bruising, bleeding or skin
discolorations, any changes in lesions or moles
Respiratory
Cough, wheezing, hemoptysis, dyspnea, pneumonia
hx, TB
Eyes
Corrective lenses, blurring, visual changes of any
kind
Gastrointestinal
Abdominal pain, N/V/D, constipation, hepatitis,
hemorrhoids, eating disorders, ulcers, black tarry
stools
Ears
Ear pain, hearing loss, ringing in ears, discharge
Genitourinary/Gynecological
Urgency, frequency burning, change in color of
urine.
Contraception, sexual activity, STDS
Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx
Male: prostate, PSA, urinary complaints
Nose/Mouth/Throat Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain Musculoskeletal Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis
Breast SBE, lumps, bumps or changes
Neurological
Syncope, seizures, transient paralysis, weakness,
paresthesias, black out spells Heme/Lymph/Endo
HIV status, bruising, blood transfusion hx, night
sweats, swollen glands, increase thirst, increase
hunger, cold or heat intolerance
Psychiatric
Depression, anxiety, sleeping difficulties, suicidal
ideation/attempts, previous dx
OBJECTIVE
Weight BMI Temp BP Height Pulse Resp General Appearance
Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately.
Slightly somber affect at first, then brighter later. Skin
Skin is brown, warm, dry, clean and intact. No rashes or lesions noted. HEENT
Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs
intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive
light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation.
Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules.
Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair. Cardiovascular
S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds.
Pulses 3+ throughout. No edema. Respiratory
Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally. Gastrointestinal
Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly. Breast
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin. Genitourinary
Bladder is non-distended; no CVA tenderness. External genitalia reveal coarse pubic hair in normal
distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized.
A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink
and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT.
Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.
No adnexal masses or tenderness. Ovaries are non-palpable.
(Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. )
(Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is
smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm). Musculoskeletal
Full ROM seen in all 4 extremities as patient moved about the exam room. Neurological
Speech clear. Good tone. Posture erect. Balance stable; gait normal. Psychiatric
Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though
clear and of normal rate and cadence; answers questions appropriately.
Lab Tests
Urinalysis – pending
Urine culture – pending
Wet prep – pending
Special Tests
Diagnosis
Differential Diagnoses
o 1- o 2- o 3-
Diagnosis
o
Plan/Therapeutics
o Plan: ▪ Further testing ▪ Medication ▪ Education ▪ Non-medication treatments
Evaluation of patient encounter
RUBRIC
QUALITY OF RESPONSE NO RESPONSE POOR / UNSATISFACTORY SATISFACTORY GOOD EXCELLENT Content (worth a maximum of 50% of the total points) Zero points: Student failed to submit the final paper. 20 points out of 50: The essay illustrates poor understanding of the relevant material by failing to address or incorrectly addressing the relevant content; failing to identify or inaccurately explaining/defining key concepts/ideas; ignoring or incorrectly explaining key points/claims and the reasoning behind them; and/or incorrectly or inappropriately using terminology; and elements of the response are lacking. 30 points out of 50: The essay illustrates a rudimentary understanding of the relevant material by mentioning but not full explaining the relevant content; identifying some of the key concepts/ideas though failing to fully or accurately explain many of them; using terminology, though sometimes inaccurately or inappropriately; and/or incorporating some key claims/points but failing to explain the reasoning behind them or doing so inaccurately. Elements of the required response may also be lacking. 40 points out of 50: The essay illustrates solid understanding of the relevant material by correctly addressing most of the relevant content; identifying and explaining most of the key concepts/ideas; using correct terminology; explaining the reasoning behind most of the key points/claims; and/or where necessary or useful, substantiating some points with accurate examples. The answer is complete. 50 points: The essay illustrates exemplary understanding of the relevant material by thoroughly and correctly addressing the relevant content; identifying and explaining all of the key concepts/ideas; using correct terminology explaining the reasoning behind key points/claims and substantiating, as necessary/useful, points with several accurate and illuminating examples. No aspects of the required answer are missing. Use of Sources (worth a maximum of 20% of the total points). Zero points: Student failed to include citations and/or references. Or the student failed to submit a final paper. 5 out 20 points: Sources are seldom cited to support statements and/or format of citations are not recognizable as APA 6th Edition format. There are major errors in the formation of the references and citations. And/or there is a major reliance on highly questionable. The Student fails to provide an adequate synthesis of research collected for the paper. 10 out 20 points: References to scholarly sources are occasionally given; many statements seem unsubstantiated. Frequent errors in APA 6th Edition format, leaving the reader confused about the source of the information. There are significant errors of the formation in the references and citations. And/or there is a significant use of highly questionable sources. 15 out 20 points: Credible Scholarly sources are used effectively support claims and are, for the most part, clear and fairly represented. APA 6th Edition is used with only a few minor errors. There are minor errors in reference and/or citations. And/or there is some use of questionable sources. 20 points: Credible scholarly sources are used to give compelling evidence to support claims and are clearly and fairly represented. APA 6th Edition format is used accurately and consistently. The student uses above the maximum required references in the development of the assignment. Grammar (worth maximum of 20% of total points) Zero points: Student failed to submit the final paper. 5 points out of 20: The paper does not communicate ideas/points clearly due to inappropriate use of terminology and vague language; thoughts and sentences are disjointed or incomprehensible; organization lacking; and/or numerous grammatical, spelling/punctuation errors 10 points out 20: The paper is often unclear and difficult to follow due to some inappropriate terminology and/or vague language; ideas may be fragmented, wandering and/or repetitive; poor organization; and/or some grammatical, spelling, punctuation errors 15 points out of 20: The paper is mostly clear as a result of appropriate use of terminology and minimal vagueness; no tangents and no repetition; fairly good organization; almost perfect grammar, spelling, punctuation, and word usage. 20 points: The paper is clear, concise, and a pleasure to read as a result of appropriate and precise use of terminology; total coherence of thoughts and presentation and logical organization; and the essay is error free. Structure of the Paper (worth 10% of total points) Zero points: Student failed to submit the final paper. 3 points out of 10: Student needs to develop better formatting skills. The paper omits significant structural elements required for and APA 6th edition paper. Formatting of the paper has major flaws. The paper does not conform to APA 6th edition requirements whatsoever. 5 points out of 10: Appearance of final paper demonstrates the student’s limited ability to format the paper. There are significant errors in formatting and/or the total omission of major components of an APA 6th edition paper. They can include the omission of the cover page, abstract, and page numbers. Additionally the page has major formatting issues with spacing or paragraph formation. Font size might not conform to size requirements. The student also significantly writes too large or too short of and paper 7 points out of 10: Research paper presents an above-average use of formatting skills. The paper has slight errors within the paper. This can include small errors or omissions with the cover page, abstract, page number, and headers. There could be also slight formatting issues with the document spacing or the font Additionally the paper might slightly exceed or undershoot the specific number of required written pages for the assignment. 10 points: Student provides a high-caliber, formatted paper. This includes an APA 6th edition cover page, abstract, page number, headers and is double spaced in 12’ Times Roman Font. Additionally, the paper conforms to the specific number of required written pages and neither goes over or under the specified length of the paper. GET THIS PROJECT NOW BY CLICKING ON THIS LINK TO PLACE THE ORDER
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